When Massage Therapy Creates an Adverse Effect

By Ruth Werner
[Pathology Perspectives]

Most people wouldn’t argue with the idea that massage therapy has many benefits to offer clients. However, if we’re going to make the statement that massage is powerful enough to cause positive outcomes, then we also need to recognize that it is powerful enough to cause some negative outcomes, too. Indeed, some states’ licensure laws rely on evidence of potential harm, rather than on evidence of potential benefit, to make the case that regulation is in the public interest.
Massage is Good, Right?
Exactly what benefits massage therapy has to offer, and the mechanisms that bring them about, are issues we are still exploring. Acute and chronic pain management (regardless of the cause of pain) is one of the things we do best, and strong evidence points to massage therapy as a useful strategy in dealing with anxiety, depression, and some musculoskeletal issues like injured muscles, strained tendons, and various forms of arthritis.
In addition, human beings have an innate need for welcomed touch. In the United States, there are very few contexts in which it is considered appropriate: greetings and goodbyes, grooming, health care, and sexuality. No wonder we love the idea of receiving prolonged, educated, nonjudgmental touch!

What is an Adverse Effect?
An adverse effect, or adverse event, is any harmful or undesired outcome. It can be minor, like mild soreness the day following a massage, to catastrophic and life-threatening, like fragmenting a deep venous thrombosis and creating a pulmonary embolism. Failure to achieve a positive outcome is not an adverse effect, however.
Every health-care intervention has the potential for an adverse effect, and the more invasive an intervention, the higher the risk. A patient might go into surgery for a well-established procedure, like knee replacement for instance, and develop a blood clot or an infection that could unexpectedly end his life.
We don’t hear about it often, but this sort of thing can happen with massage, too. Here is an excerpt from a letter I received:
“A healthy, active older woman who was on vacation in my town came to me for a massage. She was complaining about a lot of neck pain, so I did some focused work on her sternocleidomastoid muscles. She seemed happy with the session, and went home. Later I heard that she had had a massive stroke that night. Now I’m worried: was that my fault?”
One of the tricky things about identifying adverse effects of massage is that events could be linked to lots of other triggers as well. When something unexpected happens—especially something bad—people tend to attribute it to an activity that was out of the ordinary. This makes sense, but linking the effect to massage as a cause is not always accurate. In the case described in the letter, it is possible that the massage fragmented a clot in the client’s carotid artery. It is also possible that the act of climbing the stairs to her house, or taking a hot shower, or holding a phone to her ear with her shoulder did the same thing.
Some Anecdotal Examples
In preparation for writing this article, I put out a call among my associates to share—anonymously—their experiences with adverse effects. Some of them were mild; others much more disturbing. Here are a few responses:
• “I worked on a client who was about five months pregnant with her first child. She’d been having pain in her shoulders and chest. The obstetrician attributed it to her job, and gave an OK for her to receive massage. I did a standard, safe treatment with some attention to her pecs, traps, and whole upper back; nothing fancy. She woke up the next day in excruciating pain, and it hurt to breathe. It turns out she had costochondritis, and the massage had kicked it into overdrive. She treated it with ice and ultrasound, and continued to receive careful massage through the rest of her pregnancy.”
• “I was performing a scapula pull/retraction on a client when my hand slipped and I caught a mole with my fingernail. It came off, bleeding and all! I had to dress the wound on the spot.”
• “I had a client who requested deep tissue work. I asked her lots of questions about her health, and she denied any pathologies. Fifteen minutes into working around her low back, I noticed that she seemed highly congested in that area. She still denied any problems, but I stopped the massage anyway. I sent her on her way, with a request that she let me know if she developed any problems. The next day, her daughter called, saying I had ‘screwed her mother up.’ Her mother’s low back and abdomen were swollen and she was having trouble urinating. Finally, she told me that her mother had severe lupus. I advised that she get to the ER as quickly as possible. My client spent four days in the ICU, and I had to explain to three different medical specialists what triggered her symptoms; they didn’t believe that a massage could lead to this potentially lethal inflammation.”
• “I had a client with very tight neck and shoulder muscles that caused a lot of pain. She wanted me to help her resolve it. I worked gently, but she was much worse after the first session and the second session didn’t help either. It was only then that she told me she had been diagnosed with cervical stenosis.”
Adverse Effects: On the Record
Because the previous stories are anecdotes, they are not in the official or academic literature about possible adverse effects of massage. However, a quick search in PubMed for “massage therapy adverse effects” yields plenty of examples.
One article provides a systematic review (a wide-scale compilation) of adverse events related to massage between 2002 and 2012.1 It compiles data on 18 reports of significant injuries that include acute paraplegia, bladder rupture, cervical cord injury, ischemic stroke, pulmonary embolism, rhabdomyolysis, vertebral artery dissection, and many others. Most of these are case reports (that is, a description of a single event), and one is a case series involving many clients with the same intervention.
In five of the events, the massage was provided by a trained massage therapist; the other events involved untrained or unqualified people, or did not specify who provided the massage. It is interesting to note that four of the reports (including a case series involving 238 clients) involved massage devices rather than hands-on work. This is a useful article, because it suggests that good training is a way to avoid these unfortunate outcomes.
Several other published reports of damage related to massage are available. One described a deep-tissue massage causing spinal accessory neuropathy, which led to trapezius weakness and scapular winging.2 Another reported a case in which shiatsu massage collapsed and fragmented stents located in the iliac arteries.3 Interestingly, this was found during surgical follow up; the client had no signs or symptoms and his leg circulation was normal.
In a less successful case, a client with some ossification of the posterior longitudinal ligament was given a massage. “The massage was performed in such a manner that the massage therapist pressed the patient’s back with the palm and then pushed it in an upward direction from the thoracic to the cervical in a prone position.”4 This appears to have led to an incomplete spinal cord injury, surgery, and long-term loss of function.
It is important to point out that this case was unusual in that it led to a long-term problem. The vast majority of the adverse effects reported in the literature led to some need for medical intervention, but little or no enduring damage.
What Can We Do?
By and large, massage therapy is a safe intervention with relatively low risk (especially in comparison with drugs or surgery). But “low risk” isn’t “no risk,” and we have the responsibility to minimize the chances of any adverse events.
In the investigation of whether an intervention is safe, it is often compared to “usual care.” In this comparison, usual care is often the safest—that is, it carries the least risk—but it may leave out powerfully positive options (like massage). That’s a risk, too, because it’s not ethical to deprive patients of a treatment that could be highly effective.
There are only a couple of ways for massage-related injuries to be officially recorded. A case report may make it into a research journal, or an injured client may bring suit against a massage therapist—those cases are almost always settled out of the public eye, but records are kept by liability/malpractice insurance providers who may be involved.
This presents a problem because without a way to freely and openly document and share errors, we can’t learn from each other’s mistakes. Further, the rarity of recorded adverse effects—while a good reflection of the relative safety of massage—can also make it difficult to suggest that this profession requires appropriate education and regulation in the interest of public protection.
Our best action is to be vigilant in protecting our clients, and well informed about published adverse events. When the unexpected happens in our own practice, we need to be brave enough to share that information in a publishable case report. Massage therapists wrote none of the academically recorded reports described in this article; they were all recorded by the physicians who dealt with the aftermath.
If our profession is going to earn a place alongside other health-care providers, we need to be willing to speak out when we have a negative outcome. As long as we can demonstrate that we have delivered an appropriate standard of care, and if our clients give permission, we can safely write case reports that describe what happened when a massage went wrong.
This will do three important things: it shows that massage is powerful enough to cause an occasional problem; it allows others in the profession to learn from our mistakes, and it demonstrates that we can take responsibility for our clients’ well-being. So here is the call to action: Work hard to not make mistakes. And when a mistake happens, be prepared to report it to your profession so others can learn through you.
1. P. Posadzki and E. Ernst, “The Safety of Massage Therapy: An Update of a Systematic Review,” Focus on Alternative and Complementary Therapies 18, no. 1 (2013): 27–32.
2. I. A. Aksoy et al., “Spinal Accessory Neuropathy Associated with Deep Tissue Massage: a Case Report,” presented to the American Association of Neuromuscular and Electrodiagnostic Medicine, October 13, 2007, Phoenix, Arizona.
3. S. Ichihashi et al., “Fracture and Collapse of Balloon-Expandable Stents in the Bilateral Common Iliac Arteries Due to Shiatsu Massage,” Cardiovascular and Interventional Radiology 35, no. 6 (2012): 1,500–4.
4. H. Cheong et al., “Spinal Cord Injury Incurred by Neck Massage,” Annals of Rehabilitation Medicine 36, no. 5 (2012): 708–12.
Author’s note: my thanks to the brave and generous massage therapists who shared their stories here. Please consider writing a case report on these events!

Ruth Werner is a former massage therapist, a writer, and a continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

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